INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 5, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Empowerment Resurrection Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
|
Observations
Based on an interview with a governing body member and a review of the Staffing Requirements Facility Summary Report, the facility failed to employ both a project director and facility director.
The findings include:
An interview with a governing body member who was involved in the licensing renewal inspection and a review of the Staffing Requirements Facility Summary Report was completed on March 5, 2015. The facility failed to procure both a facility director and project director from February 2014 to March 2015.
These findings were reviewed with a governing body member during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the March 21, 2014 inspection.
|
Plan of Correction
A project director was hired on April 1, 2015 and an interim facility director was selected on June 27, 2015. A permanent facility director will be hired by July 30, 2015. If the project director or facility director resigns, or is unable to continue in the position for any reason, the board of directors will be notified immediately by the board president. A board member who is qualified to serve as the interim project or facility director has been identified. This board member will assume the position of interim project director or interim facility director within 48 hours of the project or facility director position becoming vacant. The president of the board of directors is responsible for insuring that ERC has a project director and facility director at all times. A subcommittee was formed to recruit, interview and select a facility director in accordance with the job requirements outlined in ERC's policies. This subcommittee reports to the board president. The interim facility director will fulfill all duties of the position until s/he is replaced by a permanent facility director. The interim facility director reports to the board of directors and will attend all board meetings while s/he is serving in the capacity of the interim facility director. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all fire extinguishers were inspected and approved annually.
The findings include:
A physical plant inspection was conducted on March 5, 2015 at approximately 9:00 AM.
The facility failed to ensure that the fire extinguisher located on the wall next to the reception desk was inspected and approved annually. The fire extinguisher was last inspected and approved in November 2013.
These findings were reviewed with a governing body member during the licensing process.
|
Plan of Correction
The president of the board of directors is responsible for insuring that the fire extinguishers are inspected and approved annually in the absence of a facility director. The fire extinguisher next to the reception desk was inspected on March 27, 2015 by Signal Fire Protection, Inc. The president of the board will have the fire extinguisher inspected one month before it is due to expire. The president of the board of directors will check that the extinguisher is inspected as scheduled, and will schedule the inspection if it is not completed by the week before it expires. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drill records, the facility failed to conduct a fire drill at least once a month.
The findings include:
A review of the facility's fire drill records from January 2014 - February 2015 was conducted on March 5, 2015. There was no documentation of an unannounced fire drill in March 2014 and April 2014.
These findings were reviewed with a governing body member during the licensing process.
|
Plan of Correction
Effective immediately a fire drill will be conducted by the president of the board of directors each month by the 15th day of the month and documented on the fire drill log posted in the office. The president of the board is responsible for insuring that the fire drills are conducted in the absence of the facility director. Once the facility director has begun his position on April 1, 2015, he will assume this responsibility. The president of the board of directors will check the fire drill log on the 15th of the month. If a fire drill has not occurred, the president of the board will conduct one before the 20th of the month and document it. |